National Trends in Racial and Ethnic Disparities in Use of Recommended Therapies in Adults with Atherosclerotic Cardiovascular Disease, 1999-2020

Key Points Question How have racial and ethnic disparities in the utilization of guideline-recommended therapies for secondary prevention among US adults with atherosclerotic cardiovascular disease (ASCVD) changed over the past 2 decades? Findings In this cross-sectional study of 5218 US adults with ASCVD, we observed significant improvements in cholesterol control, statin use, and angiotensin-converting enzyme inhibitor and angiotensin receptor blocker use among all racial and ethnic subgroups, as well as smoking cessation among Hispanics and Latino individuals. However, a substantial gap persisted between current care and optimal care, with only 50% of patients overall adopting optimal prevention strategies across racial and ethnic subgroups. Meaning These results suggest that, despite efforts to enhance the quality of care for ASCVD patients, substantial disparities persist between current care and optimal care, underscoring the urgent need for ongoing initiatives to bridge these gaps and improve outcomes for all patients, regardless of their backgrounds.


Data Collection in NHANES
NHANES is a series of cross-sectional, multistage, weighted surveys that provide nationally representative estimates for the non-institutionalized US population. 1 In-home interviews are conducted with all participants, and a random subsample of participants also undergo standardized physical examinations and provide blood and urine specimens for laboratory testing. 2 During the in-home interview, detailed information on participants' demographics, socioeconomic status, and medical history was collected.Demographic and socioeconomic variables included age, sex, education level, family income (based on the percent of family income relative to the federal poverty limit from the Census Bureau), insurance status, marital status, employment status, smoking status, and alcohol intake.Physical activity was categorized into three groups -inactive (no participation or fewer than 10 minutes of moderate or vigorous physical activity per week), insufficient (between 10-149 minutes per week of moderate physical activity or between 10-74 minutes per week of vigorous physical activity), and recommended (150 minutes or more of moderate physical activity or 75 minutes or more of vigorous physical activity per week) -based on established physical activity guidelines. 3,4 he definitions of these covariates are provided in Supplementary Table S1.We also obtained information on the use of medication, including aspirin, statin, angiotensin-converting enzyme inhibitor (ACEI), and angiotensin II receptor blocker (ARB), by self-report and review of participant prescription medication bottles.Physical examinations were conducted by trained staff who measured participants' weight and height to calculate body mass index (BMI), with obesity defined as a BMI ≥30 kg/m 2 .Blood pressure was measured using a mercury sphygmomanometer after the participant rested quietly in a seated position for at least 5 minutes.Three blood pressure measurements were obtained, and the mean of all measurements was used in analyses.Blood samples were collected at the mobile examination center and then sent to central laboratories for analysis.Standard methods were used to determine total cholesterol, high-density lipoprotein (HDL) cholesterol, low-density lipoprotein (LDL) cholesterol, triglycerides, plasma glucose, and hemoglobin A1c.Fasting blood samples collected over an eight-hour period were available in a subsample of survey participants for measuring LDL cholesterol, triglycerides, and glucose.In-person interview: Please describe your current marital status.
Marital status is classified as married/ living with partners vs. others (widowed, divorced, or separated; and never married).

Highest education level
In-person interview: What is the highest grade or level of school you have completed or the highest degree you have received?
Highest education level is classified as less than high school, high school, greater than high school.

Family income
In-person interview: Please describe your family income (reported as a range value in dollars) Based on percent of family income relative to the federal poverty limit from the Census Bureau, family income is categorized as high/middle income

Physical activity
In-person interview: • Behavioral Risk Factor Surveillance Survey (BRFSS) physical activity instrument.• Patients were asked if they participated in moderate or vigorous physical activity during the past 30 days.If they answered yes to either question, they were then asked the duration and frequency of their participation in physical activity for an average week.
Physical activity is classified into three levels: recommended (150 min or more of moderate physical activity or 75 min or more of vigorous physical activity per week), insufficient (between 10-149 min per week of moderate physical activity or between 10-74 min per week of vigorous physical activity), or inactive (no participation or fewer than 10 min of moderate or vigorous physical activity per week).

Obesity
All participants ages 2 and older had their standing height and weight measured during their physical examination.
Obesity is defined as body mass index (BMI)≥ 30kg/m 2 , where BMI is calculated as weight divided by the square of height.

Diabetes
In-person interview: • Are you now taking diabetic pills to lower your blood sugar?These are sometimes called oral agents or oral hypoglycemic agents.• Are you now taking insulin?
• Self-reported use of prescription medications during a one-month period prior to the survey date.
Lab measurement: All participants ages 12 and older are given the option of a HbA1C% test during their physical examination.Besides, Participants aged 12 years and older who were examined in the morning session were tested for fasting glucose.

Hypertension
In-person interview: Are you now taking prescribed medicine for high blood pressure (BP) Examination measurement: Blood pressure (BP) is measured on all examinees 8 years and older.
Hypertension is defined as average systolic blood pressure >=140, or averaged diastolic blood pressure>=90, or currently on antihypertensive medication.

Chronic kidney disease
Lab measurement: • All Participants aged 12 years and older are tested creatinine, which can be applied to estimate Chronic kidney disease is defined as estimated glomerular filtration rate (eGFR) < 60 ml/min/1.73m

eTable 1 .
Definition of Sociodemographic, Behavioral, and Clinical Variables in NHANES Secondary Prevention and Risk Reduction Therapy for Patients with Atherosclerotic Cardiovascular Disease Blood Pressure Trends in NHANES Participants Reporting Prior Atherosclerotic Cardiovascular Disease, by Race and Ethnicity Blood Glucose Trends in NHANES Participants Reporting Prior Atherosclerotic Cardiovascular Disease, by Race and Ethnicity 2 , or urinary albumin-to-creatinine ratio >= 30mg/g.© 2023 Lu Y et al.JAMA Network Open.© 2023 Lu Y et al.JAMA Network Open.eTable 2. © 2023 Lu Y et al.JAMA Network Open.© 2023 Lu Y et al.JAMA Network Open.© 2023 Lu Y et al.JAMA Network Open.eTable 5. © 2023 Lu Y et al.JAMA Network Open.eTable 6. © 2023 Lu Y et al.JAMA Network Open.